HomeMy WebLinkAboutBURLWOOD TERRACE BLK 3 LT 4C,C>?
GREATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99507
279-8686
DATE RECEIVED:
INSPECT:
T I M E:
APPROVAL OF
AND WATER FACILITIES
FOR
REQUEST FOR
INDIVIDUAL SEWER
APPROVAL REQUESTED BY:
ADDRESS: i ' 3--,.~(3
PHONE:
PROPERTY OWNER:~'~,
LEGAL DESCRIPTION: ~c~I(.~(>(~D
TYPE FACILITY TO BE INSPECTED:"~uOI~
NUMBER OF BEDROOMS:
PHONE: ,~ ?
STREET:
WELL DATA:
A. TYPE
B. DEPTH
C. SIZE
Do CONSTRUCTION
E. BACTERIAL ANALYSIS
SEWAGE DISPOSAL SYSTEM: ",': ~.~'~;/ '~/~'-~- ~"~-~'~
^. SE~YIC Y^~ (Ir ,O~E~^~E, S.O~ ~Z^~^~ O~ ~^C~)
1 . SIZE
2. AGE
3. MANUFACTURER
4. INSTALLER
APPROVAL REQUEST FOR SEWER & WATER FACILITIES
PAGE TWO
SEEPAGE PIT
1. SIZE
2. LINING
DISPOSAL FIELD
1. NUMBER OF LINES
2. TOTAL LENGTH
REQUIRED MEASUREMENTS
A. WELL TO SEPTIC TANK
B. WELL TO SEEPAGE PIT
C. WELL TO SEWER LINE
D. WELL TO PROPERTY LINE
E. WELL TO OTHER POSSIBLE CONTAMINATION
F. FOUNDATION TO SEPTIC TANK
G. FOUNDATION TO SEEPAGE PIT
H. SEEPAGE PIT TO PROPERTY LINE
COMMENTS:
APPROVED:
DATE:
DATE:
APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALIT
G~=ATER ANCHORAGE AREA BOROUG,~
1. APPROVAL
ADDRESS:
PHONE:
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99507
279-8686
DATE RECEIVED:
INSPECT:
TIME:
REQUEST FOR APPROVAL
INDIVIDUAL SEWER AND WATER
FOR
OF
FACILITIES
REQUESTED BY:
2. PROPERTY OWNER:
3. LEGAL DESCRIPTION:
4. TYPE FACILITY TO BE
NUMBER OF BEDROOMS:
, ,.. - ,-,'-.... PHONE:
- ./~-/.,,z ' ':"-' STREET:
INSPECTED: ,,/,~,.
WELL DATA:
B. DEPTH L': ['"
C. SIZE
D. CONSTRUCTION /' ~
E. BACTERIAL ANALYS IS~ ~ / ~
SEWAGE DISPOSAL SYSTEM' ~-z.-:z/ .~,'~/~i~
A. SEPTIC TANK (IF HOMEMADE, SHOW DIAGRAM ON BACK)
-
1. SIZE
2. AGE
MANUFACTURER
INSTALLER
APPROVAL REQUE~ FOR SEWER & WATER FACILII~S
PAGE TWO
B. SEEPAGE PIT
1. SIZE
2. LINING
C. DISPOSAL FIELD
1. NUMBER OF LINES
2. TOTAL LENGTH
REQUIRED MEASUREMENTS
A. WELL TO SEPTIC TANK
B. WELL TO SEEPAGE PIT
C. WELL TO SEWER LINE
D, WELL TO PROPERTY LINE
E. WELL TO OTHER POSSIBLE CONTAMINATION
F. FOUNDATION TO SEPTIC TANK
G. FOUNDATION TO SEEPAGE PIT
H. SEEPAGE PIT TO PROPERTY LINE
COMMENTS:
DATE: ,/~ -""~C> '"' '~/'~ DATE:
APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY
iREATER gNCHOP~GE ,~REA BOROUGH
!-~L~i DF.P~R~ENT
327 E~GL£ STREET
ANCHORAGE, ALASKA 99SOi
279-2S1!
ATE CrIVrt
/// 'OD
T I ,.'.,IE: , _
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
FOn
Phone
Approval Requested By ~f~,9__ f(~__ ~
Address ~5'd~)~9 ,
Phone. c7~ 7 f' '-- .':'~ '~ ~ 7
Property Owner
Type of Facility to be Inspected.
Number of Bedrooms ~
S. Well Data:
D. Construction ~/~flf2/~ -- f~-'
E. gacterial .~alysis
6. Sewage Disposal System:
A. Septic Tank (If homemade, show diagram on back)
1. Size
2. Age
3. Hanufacturer
4. Installer
Approval Request for
Page T~o
Seepage Pit
1. Size
2. Lining
C Disposal Field
1. Number of Lines
,.' Total Length
Required Measurements
A. Well to Septic Tank
B. Well to Seepage Pit
C. Well to Sewer Line
Well to Property Line
Water Facilities
E. Well to Other Possible Contamination
F. Foundation to Septic Tank
G. Foundation to Seepage Pit
H. Seepage Pit to Property Line
8. CO,Vfl~ENTS:
APPROVED: ~. DISAPPROVED:
DATE:~DATE:
APPROVAL VALID FOR ONE YEAR FRO~] DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT
EDll70
REQUEST FOP, APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
~ame of person requesting approval ~'~ .
~tan~ of property; owner ~,.~.~,_
[.~ya] description ~ ~
4. Numb~x~ 'of bedrooms in house
Water Analysis:
b. Detergent .
6. Well data:
a. Type
b. Depth
c. Casing Size
dt
Distance from well to closest existing or proposed:
1. Sewer line
2, Septic tank
3. Seepage Area
4. Cesspool'
5. Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc. .
7. Sewage disposal system.
a. Age of system
b. Septic tank capacity in gallons .
c. Name of septic tank manufactumer
1. If "home made" show diagram on reverse side of this form·
d.' Disposal field or seepase pit size and type
to house foundation
1. Distance to property, line
e, Percolatic~ T~st '~es.ults ,
f. Percolation Test performed by
Use the reverse,side of this form to show diagram. Diagram should include
.'-the foilowing information: pFoperty lines;.well location, house location,
.~ptic tank location, disposal area location, location of percolation test,
a~ direction of ground slope.
9. The l~rfc~x~a~ion on this form is true and correct to the best of my knowledge.
Szgnature '0~ APplican~
~ate Signed-'
TO BE FILLED OU'I" BY HEALTH DEPAET~.~ENT PERSONNEL
~-~+f~e above described sanitary facilities are hereby approved subject, to the
......... ~6'l~owing cond~ions i ' ...........
Conditions: _ ~.~~~ <~c.k_~_~,,.~z-~j~..,~._ /~.~ ~'
The above described sanitary facilities are disapproved for the following
re aso~ls:
Signature of ~.f~i'¢f'~l..~ .v '- . ,'"~...-: .i. ' ' : ~ate - ,' . ~;~,' :..~ ,2
Approval is valid for one year following the date of approval,
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